Mindfulness Screener Form Mindfulness Screener Please answer to the best of your ability - if you are not sure about something, please answer “not sure.” Contact/Personal Information Name:(Required) Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Email(Required) Do you want a copy of your responses?(Required) Yes No Patient Healthcare Information: In order to be in this group, you must have a confirmed psychiatric disorder. In your pre-group appointment with our group leaders, they will be doing a psychiatric assessment.Do you currently have a psychiatrist?(Required) Yes No Psychiatrist's Name: Do you currently have a therapist?(Required) Yes No Therapist's Name: Who is referring you to the Mindfulness Group? Do you currently have an anxiety disorder?(Required) Yes No What anxiety disorder? Does your anxiety disorder functionally impairing to you or causing significant distress in your life? Yes No Is your anxiety disorder present at all times? Do you have a depressive disorder?(Required) Yes No What is your disorder? Have you had more than one depressive episode? Yes No How many? Are you currently depressed? Yes No I am interested in the Monday afternoon group with Jack Nitschke Yes No I am interested in the Wednesday Morning group with Stuart Jones Yes No I would like to wait for the next session Yes No Insurance Information: Do you have insurance?(Required) Yes No With who? Quartz and Medicare cover this group, please note, however, co-pays will apply. If there is a copay involved, it would be that times the number of group sessions (8). If you have GHC or Dean insurance, you need to contact them for a prior authorization BEFORE your appointment can be scheduled, and please take note that they do not usually authorize for this group here If you do not have Quartz, Medicare, Dean or GHC insurance, and you do not know what your insurance covers, you will have to contact your insurance carrier and ask them if they cover billing code for group-90853 (mental health visit). Co-pay would be times the number of group sessions (8). The initial pre-group intake appointment falls under billing code 90792. Pre-Screening Questions: Have you ever been in a mindfulness class with us before?(Required) Yes No Which one? Anxiety Depression Both Approximate Dates: Have you had any inpatient hospital stays in the last year?(If yes, a group leader may need to call you and speak to you more about this)(Required) Yes No Are you actively suicidal or engaged in any self-harm?(If yes, a group leader may need to call you and speak to you more about this)(Required) Yes No Have you participated in a DBT (Dialectical Behavior Therapy) group? (If yes, a group leader may need to call you and speak to you more about this)(Required) Yes No Scheduling Pre-Group Appointment After you return your answers, and if there is no need for further contact from the group leaders before proceeding, I will then send you (via email) a set of appointment options to meet with one of the group leaders before group begins. When your ranking of these appointment options comes back to me, I will get you scheduled for your pre-group intake appointment with one of the group leaders in preparation for the group. Please note, you will *not* be an active member of the class until we have completed all information, verified information, and have let you know that you are accepted into the group. And also, last but NOT least, please feel free to contact me if I can be of any other assistance Megan